AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
The information on this website is general in nature and does not take into account your objectives, financial situation, or needs. Consider seeking personal advice from a licensed adviser before acting on any information.
A recent ruling by the Australian Financial Complaints Authority (AFCA) has affected a woman’s critical illness claims, as her diagnosis came within mere days of her policy's eligibility period drawing to an end.
The woman was diagnosed with cancer in her right breast on October 5 of last year, followed by the discovery of cancer in her left breast eight days later. She filed claims under her critical illness policy that she had obtained on July 17.
However, TAL Life, her insurance provider, rejected the claims based on the policy's three-month qualifying period for cancer coverage.
In its ruling, AFCA noted that the policy had provisions to potentially waive the qualifying period if the policyholder could prove they were insured either under a previous TAL policy or by another insurer for the same events, right before their new coverage commenced.
The claimant contended that she had cancer coverage through an insurance policy provided by her husband's employer. She presented a letter from the employer affirming that she was covered under a "life, accident, critical illness, and medical insurance" scheme from August 2020 until June last year. Additionally, she showed documentation indicating her husband’s policy did include critical illness coverage for spouses, encompassing cancer.
While AFCA accepted the availability of this cancer coverage, it was not convinced that she held such coverage "immediately before the current policy began." It also noted she had failed to disclose her previous insurance when applying for the new policy with TAL Life.
"There is no information before me about the extent of the critical illness cover the complainant had, if any, through her husband's employer’s insurance arrangements," AFCA’s ombudsman stated.
"Furthermore, it appears that any cover she might have had ceased about a month before the new policy started. I am not convinced there was 'continuity of cover' as suggested by the complainant."
The ombudsman expressed AFCA’s sympathy towards the claimant, especially given that the diagnoses occurred "very close to the end of the qualifying period." Nonetheless, he emphasized that there was no valid reason for the qualifying period to be dismissed.
"The qualifying period is reasonably short and its existence is not unjust. These terms are part of all insurance policies and they draw necessary boundaries. The enforcement of these terms is not inherently unfair," the ombudsman elaborated.
For a more detailed account of the ruling, refer to the original report by AFCA.
Please Note: We do not endorse any specific products or companies. Some content is sourced from third parties, including press releases, and may not be independently verified for accuracy or completeness.
ASIC’s ongoing focus on general insurance claims handling is a timely reminder that the value of a policy is tested long after the premium is paid. For Australian tradies, the issue is practical rather than theoretical: when a ute is damaged, tools are stolen, a workshop is hit by stormwater or a client alleges property damage, delays and documentation gaps can quickly affect cash flow. - read more
A new Australian Financial Complaints Authority decision has put income protection claims under the spotlight, with useful lessons for tradies who rely on their own capacity to work. The dispute involved a delivery driver who had received weekly income protection benefits after a serious arm-related medical condition prevented him from working. The insurer later tried to recover more than $31,000 in paid benefits, arguing it had information suggesting he could have returned to work earlier. - read more
QBE’s decision to stop offering its standalone office and trade pack products from July 2026 is a timely reminder for Australian tradies to treat every renewal as more than a simple rollover. The insurer is moving customers towards a standard business cover structure, with existing trade pack policyholders expected to be offered the replacement product at renewal from October 2026. - read more
The Insurance Council of Australia’s redrafted General Insurance Code of Practice has moved into consultation, with submissions open until 21 July 2026 and a transition period of around two years expected if the code proceeds. For trade business owners, the headline change is that key insurer commitments are intended to become contractually enforceable, rather than sitting only as industry standards. - read more
The Australian Prudential Regulation Authority (APRA) is set to host the 2026 AFR Insurance Summit on June 16 at The Fullerton Hotel in Sydney. This pivotal event will bring together industry leaders to address pressing issues within Australia's insurance sector, with a particular emphasis on climate-related risks, insurance affordability, and maintaining public trust. - read more
Insurance is a crucial safety net for tradespeople, protecting against unforeseen mishaps that can disrupt their work and finances. Whether you're a carpenter, electrician, plumber, or any other skilled trade professional, having the right insurance can make a significant difference in your business continuity and peace of mind. - read more
Public liability insurance is a type of coverage designed to protect businesses against claims of property damage or personal injury caused by their work. This type of insurance is essential for trades professionals, as it provides financial protection against legal and compensation costs arising from incidents related to their services. - read more
In the world of trades, having the right financial products can make a significant difference in managing your business effectively. Whether you're a plumber, electrician, carpenter, or any other type of tradesperson, financial products such as insurance, loans, and savings accounts play a crucial role in protecting your livelihood and ensuring sustainable growth. - read more
Have you ever thought about making the leap from being a skilled tradie to running your own business? It's an exciting journey that many Australians are considering, as it offers the chance to not only work for yourself but also to create something meaningful in your community. - read more
Knowledgebase
Aggregate Limit: The maximum amount an insurer will pay for all covered losses during a policy period.
No comments yet. Be the first to share your thoughts.